A review of the prevalence, trends, and determinants of coexisting forms of malnutrition in neonates, infants, and children
(2022) 22:879 Khaliq et al BMC Public Health https://doi.org/10.1186/s12889-022-13098-9 Open Access RESEARCH A review of the prevalence, trends, and determinants of coexisting forms of malnutrition in neonates, infants, and children Asif Khaliq1*, Darren Wraith1, Smita Nambiar2 and Yvette Miller1 Abstract Objective: Coexisting Forms of Malnutrition (CFM) refers to the presence of more than one type of nutritional disorder in an individual Worldwide, CFM affects more than half of all malnourished children, and compared to standalone forms of malnutrition, CFM is associated with a higher risk of illness and death This review examined published literature for assessing the prevalence, trends, and determinants of CFM in neonates, infants, and children Methods: A review of community-based observational studies was conducted Seven databases, (CINAHL, Cochrane Library, EMBASE, Medline, PubMed, Scopus, and Web of Science) were used in December-2021 to retrieve literature Google, Google Scholar and TROVE were used to search for grey literature Key stakeholders were also contacted for unpublished documents Studies measuring the prevalence, and/or trends, and/or determinants of CFM presenting in individuals were included The quality of included studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal tools for prevalence and longitudinal studies Results: The search retrieved 14,207 articles, of which 24 were included in this review The prevalence of CFM varied by geographical area and specific types In children under years, the coexistence of stunting with overweight/ obesity ranged from 0.8% in the United States to over 10% in Ukraine and Syria, while the prevalence of coexisting wasting with stunting ranged from 0.1% in most of the South American countries to 9.2% in Niger A decrease in CFM prevalence was observed in all countries, except Indonesia Studies in China and Indonesia showed a positive association between rurality of residence and coexisting stunting with overweight/obesity Evidence for other risk and protective factors for CFM is too minimal or conflicting to be conclusive Conclusion: Evidence regarding the prevalence, determinants and trends for CFM is scarce Apart from the coexistence of stunting with overweight/obesity, the determinants of other types of CFM are unclear CFM in any form results in an increased risk of health adversities which can be different from comparable standalone forms, thus, there is an urgent need to explore the determinants and distribution of different types of CFM Keywords: Anthropometry, Child, Coexisting, Malnutrition, Measurement *Correspondence: asif.khaliq@hdr.qut.edu.au School of Public Health and Social Work, Queensland University of Technology, Brisbane 4059, Australia Full list of author information is available at the end of the article Introduction Malnutrition is a global health concern affecting almost every individual, irrespective of age, gender, race, social status, and geographical boundaries [1, 2] It can be defined as an imbalance of energy and nutrient intake © The Author(s) 2022 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data Khaliq et al BMC Public Health (2022) 22:879 that may alter the body measurements, compositions and functions [3, 4] Thus, malnutrition refers to both undernutrition as well as overnutrition [5] The World Health Organization (WHO) has classified malnutrition into three broad categories: undernutrition, overnutrition, and Micronutrient-Related Malnutrition (MRM) Stunting, wasting and underweight are three common types of undernutrition, while obesity is related to overnutrition MRM is further bifurcated into MRM-deficiency and MRM-overload (Fig. 1) [6] Malnutrition increases the risk of illnesses, treatment costs, hospitalisation, and deaths [7, 8] Worldwide, 2.4 million or ~ 45% of children below years of age die annually owing to malnutrition [9–11] The presence of more than one type of nutritional disorder can be referred to as Coexisting Forms of Malnutrition (CFM) Children with CFM, such as the coexistence of stunting with wasting, are more vulnerable to death than those with standalone forms of malnutrition [12] CFM occur due to the simultaneous presence of either multiple anthropometric deficits or MRM or a combination of both, in an individual Like standalone forms of malnutrition, it can be assessed either by a single method, such as using anthropometric measurements, or multiple methods that involve anthropometry, biochemical and dietary assessment [13–15] Page of 23 CFM is more complex, challenging to control and is associated with increased health risks compared to standalone forms of malnutrition [16, 17]., McDonald, et al., (2013) found that CFM affects more than half of malnourished children worldwide, and each unit increase in anthropometric deficits proportionally increased the risk of death in children While children suffering from standalone forms of malnutrition have more than two folds higher risk of death compared to healthy children, this risk increases to more than 10- fold in children suffering from CFM [18] The coexistence of stunting with overweight/obesity and coexistence of overweight/obesity with micronutrient deficiency are the two common types of CFM in overweight/obese children The management and prevention of coexistence of stunting with overweight/obesity and/or coexistence of overweight/ obesity with micronutrient deficiency is more challenging compared to standalone forms of malnutrition because it requires simultaneous prevention and management of overnutrition and undernutrition/micronutrient deficiency [19–21] Further, evidence for CFM is scarce, as global, national, and regional surveys predominantly measure the prevalence, trends, and determinants of standalone forms of malnutrition, such as stunting, wasting, underweight, overweight/obesity and micronutrient deficiency (Fig. 1) Fig. 1 Malnutrition classification and sub-classification Where, * = Micronutrient Related Malnutrition ¥ = The z-score is less than − 2.00 S D or 3rd percentile ∞ = The z-score is over + 2.00 S D or 97th percentile Khaliq et al BMC Public Health (2022) 22:879 This scoping review examined the current evidence for existing gaps in the knowledge about the prevalence, trends, and determinants of CFM worldwide in neonates, infants, and children Methodology Protocol and registration The protocol for this review was drafted following PRISMA guidelines and finalised through consultation and review with all authors and an experienced librarian [22] The PRISMA checklist associated with this scoping review can be found in Supplementary file 1 The protocol was approved by the Human Research Ethics Committee of Queensland University of Technology, Brisbane, Australia (Approval number: 2000000177) Eligibility criteria This study considered official reports from the World Health Organization (WHO), United Nation’s Children Emergency Funds (UNICEF), Centre of Disease Control and Prevention (CDC), Food and Agriculture Organization (FAO), Global Nutrition Report (GNR), Demographic & Health Survey (DHS), Scaling up Nutrition (SUN), and various community-based descriptive and observational epidemiological studies which measured the prevalence, trends, and/or determinants of CFM in children aged between to 12 years irrespective of the sample’s gender, geographical location, and the publication year [23, 24] Articles that were outside the scope of this review were excluded These were community-based studies which solely discussed micronutrient deficiencies; studies that described only one type of standalone form of malnutrition; Double Burden of Malnutrition (DBM) at the household level (for example, the coexistence of maternal obesity and paediatric stunting living in the same household); reviews, experimental or intervention trials, institutional-based studies and genomic or molecular level studies; conference proceedings, policy briefs, editorials and book chapters and studies on special populations, such as children with Down’s syndrome, cleft palate, and refugee status due to the different growth trajectories of these children compared to normal children Information sources Several databases including CINAHL (via EBSCOhost), Cochrane Library, EMBASE, Medline (via EBSCOhost), PubMed, Scopus, and Web of Science were used to identify relevant studies The literature search was carried out at various time points between 4thJuly, 2019 and 23rd December 2021 The key reports produced by the WHO, UNICEF, CDC, FAO, GNR, DHS, SUN and other relevant bodies were searched using Google, Google scholar Page of 23 and TROVE In addition, key stakeholders working in epidemiological surveillance, prevention, and control of malnutrition among women and children were contacted for unpublished records and datasets Altogether, 14,207 studies, including key findings were obtained, published over a 70-year period between 1st-November-1955 to 20th-December-2021 Of these studies, 14,184 were obtained from the aforementioned databases, while the remaining were extracted from the key finding reports of various organizations and governing bodies Search strategy All members of the research team discussed and developed the search strategy for this review and identified three keywords from the primary research question: children, coexisting forms, and malnutrition From each keyword, synonyms were searched In addition, Medical Subject Headings (MeSH) were searched from PubMed and Medline (via EBSCOhost) Keywords, MeSH, and synonyms used for different electronic database searches are presented in Table 1 The Peer Review for Electronic Search Strategies (PRESS) guidelines was consulted to improve the quality of the electronic search process Study selection, data items and data extraction process All studies obtained from different databases were imported to an EndNote library Within the EndNote library, several functions, such as duplicate removal, title screening, abstract reading, full-text reading, and eligibility determination were performed sequentially by the primary author Co-authors assisted the primary author to provide clarity through consensus if any studies were unclear The number of studies included and excluded at each step is presented in Fig. 2 Studies whose title contained any keyword or synonym related to malnutrition, child, and coexisting forms of malnutrition (Table 1) were considered for abstract and full-text screening During this phase, the following details were extracted from the articles and tabulated: study design (e.g., observational, interventional, review, reports); study population (e.g., normal residents or Table 1 Keywords, MeSH, and Synonyms for identified search terms Identified Keywords Synonyms / MeSH Child Infants, Baby, Toddler, Newborn, Neonate, Paediatric Coexisting forms Double burden, overlapping, different form Malnutrition Malnourish, Undernutrition, Overnutrition, Stunting, Wasting, Underweight, Overweight, Obese Khaliq et al BMC Public Health (2022) 22:879 Page of 23 Fig. 2 PRISMA Flow Diagram The Global Nutrition Report (GNR) reports were excluded from the quality assessment, because of methodological constraints, i.e., the data collection methods, measurement of exposure, and outcome variable in the GNR report was not described special population); study setting (e.g., community-based or institutional-based); malnutrition assessment method (e.g., anthropometry, biochemical test, clinical assessment, dietary assessment)’ malnutrition assessment level (e.g., individual, household, community); malnutrition type (e.g., standalone or coexisting forms of malnutrition) and malnutrition factors (e.g., geographical, socioeconomic, dietary, correlational) These details were used to select studies for inclusion based on the predefined eligibility criteria Summary measures and data synthesis Study populations, outcomes and statistical methods across the included studies were heterogeneous, so a narrative approach for the synthesis of results was adopted based on Economic and Social Research Council (ESRC) guidelines [25] The results of all eligible studies were categorised into four groups- “Definition & Terminology” (studies that described any phrase, term, or jargon for representing CFM), “Prevalence” (studies that described the distribution or prevalence of CFM), “Trend” (studies that described changes in the prevalence or burden of CFM with time), or “Determinants” (studies that described risk or protective factors for CFM) Quality assessment of selected studies The quality of included studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal tool for prevalence and longitudinal studies The validity and reliability of the tool have been previously evaluated [26, 27] The JBI quality assessment scale addresses the reliability and validity of selected studies [28] Each JBI Khaliq et al BMC Public Health (2022) 22:879 quality assessment scale measures the quality of studies by four factors: selection; measurement; reporting and attrition The JBI scale for prevalence studies has nine items, while the JBI quality assessment scale for longitudinal studies has eleven items Due to the varying number of items in each JBI scale The JBI assessment system uses four response options for each item: yes, no, unclear and not applicable The researcher assigned one point for each “Yes”, half point for each “Unclear” or “Not applicable” response and zero points for a “No” answer (Supplementary files 2 and 3) Results Study characteristics A total of 14,184 research articles and 23 sources of grey literature were obtained From those, 24 studies including both research articles and grey literature were included for review (see Table 2) Among the included studies, twenty-one were research studies and three were official reports of Global Nutrition The outcome variables were anthropometric indices in all selected studies, while the exposure variables included sociodemographic, socioeconomic, geographic, dietary, illness and health-related factors Among the 24 studies, fifteen studies presented CFM specifically in children, while the remaining studies examined CFM in children, adolescents and adults Together, the included studies reported CFM in the following countries: Bangladesh, Brazil, China, Ethiopia, Ghana, India, Kenya, Indonesia, Mexico, Pakistan, Senegal, Somalia, Tanzania, Thailand, Uruguay, and Vietnam Further characteristics are outlined in Figs. 3 and Fig. 4 Definitions and terminologies for representing coexisting forms of malnutrition Several terminologies were used to describe the presence of more than one form of malnutrition These include concurrent existence of malnutrition [12, 29–32], coexisting forms of malnutrition [33, 34], short and plump syndrome [35], decompensated chronic undernutrition [36] paradox [37] and dual/double burden of malnutrition (DBM) [35, 38, 39] The term DBM was used to describe individuals who were simultaneously suffering from undernutrition and overnutrition, for example, the coexistence of stunting with overweight/obesity or overnutrition with micronutrient deficiencies (i.e., the coexistence of overweight/obesity with anaemia) [20, 40] The Global Nutrition Report identified two different types of CFM in children (specifically, with stunting): coexistence of stunting with overweight/obesity, and coexistence of wasting with stunting [41–43], and these types of CFM were also described by Ferreira (2020) [36] Four other studies identified different presentations for Page of 23 CFM Fongar, et al., (2019) identified three different presentations of CFM (specifically, with obesity) at an individual level: (i) obesity with micronutrient deficiency in adults, (ii) obesity with micronutrient deficiency in children and (iii) stunting with overweight/obesity These identified combinations represent contrasting forms of malnutrition and are also known as DBM [35] Varghese, et al (2019), described five different presentations for CFM in children: (i) anaemia with overweight (ii) anaemia with underweight (iii) anaemia with stunting (iv) stunting with overweight and (v) stunting with underweight Varghese, et al (2019), also identified anaemia with underweight and anaemia with overweight in women [38] Islam & Biswas described three different types of coexisting forms of undernutrition (specifically, with underweight): (i) underweight with wasting, (ii) underweight with stunting, and (iii) underweight with wasting and with stunting [44] However, Khaliq, et al., (2021) presented four different types of CFM: (i) coexistence of underweight with wasting, (ii) coexistence of underweight with stunting, (iii) coexistence of underweight with both wasting and stunting, and (iv) coexistence of stunting with overweight/obesity [45] Prevalence of coexisting forms of malnutrition Twenty studies presented the prevalence of CFM Of these, eleven studies discussed more than one type of CFM Most studies (n = 14) examined the coexistence of stunting with overweight/obesity, followed by wasting with stunting (n = 9); coexistence of underweight with stunting (n = 7) and underweight with wasting (n = 5) The coexistence of underweight with both wasting and stunting was reported by three studies [44–46] Two studies presented the burden of coexistence of micronutrient deficiency with undernutrition (stunting or underweight) or with overweight/obesity [35, 38] (Table 3) The prevalence of CFM varied according to the geographical area and target population Globally, around 1.7% of children below 5 years of age were affected with the coexistence of stunting with overweight/obesity [42] The prevalence of coexistence of stunting with overweight/obesity among children under 5 years old was 2% in Ethiopia [30], 1% in India [38], 7.5% in Indonesia [31], 1% in Kenya [35]; between and 10% in Mexico [29]; 1.4–6.1% in Pakistan [45], 1.6% in Thailand [47], 2–3% in Uruguay [39], and 0.4–18% in China [37, 48, 49] According to the 2019 Global Nutrition Report, the global prevalence of coexistence of wasting with stunting among children below 5 years of age was 3.5% [42] The coexistence of wasting with stunting was most prevalent in Asian countries (5%), followed by African countries (2.9%), and lower again in European countries, at 2% [41] Country Brazil Mexico Uruguay Somalia Indonesia China Ghana Tanzania China Global Vietnam Publication year Florencio, et al., (2001) Fernald & Neufeld (2007) Severi & Moratorio, (2014) Kinyoki, et al., (2016) Rachmi, et al., (2016) Zhang, et al., (2016) Saaka & Galaa, (2016) Mgongo, et al., (2017) Zhang, et al., (2018) Global Nutrition Report (2018) Minh Do, et al., (2018) LS DDB CS CS CS CS CS CS CS, LS CS CS Study design 2013 to 2016 Nil 2016 2010 to 2011 2014 1991, 1993, 1997, 2000, 2004, 2006, 2009 1993, 1997, 2000, 2007 2007 to 2010 2004 to 2011, 2012 2003 1999 Study year Multistage random-clustered sampling 5017 2602 Nil 6570 1870 Strategic selection Nil Multistage sampling Multistage sampling Stratified cluster sampling Stratified random sampling 4101 2720 Two-stage cluster sampling Random sampling Nil Nil Home to home survey Sampling method 73,778 4254 children, 3524 women 7555 1247 Sample size Trend Prevalence Prevalence Prevalence – Adolescent and Adult – – – – BMI, Hb-test, BP, DM-test, Na-intake – – – – – Prevalence, Determinants, Trend Prevalence, Determinants – – – BMI, Hb-test HAZ, WHZ HAZ, WHZ to 59 months to 6 years HAZ, WAZ, WHZ, BAZ HAZ, WAZ, WHZ, Hb-test HAZ, WHZ HAZ, WAZ, WHZ, BAZ HAZ, BAZ HAZ, WAZ, WHZ HAZ, WAZ, WHZ, BAZ, Hb-level HAZ, BMI* HAZ, WAZ, WHZ Indicator to 59 months to 24 months to 59 months to 18 years 24 to 59 months to 59 months 6 years and 11 years 24 to 72 months